Parity for Mental Illness

On October 3, 2008, President Bush signed legislation authorizing the $700 billion bailout of Wall Street firms.

Due to the confusion leading up to the bailout’s passage, many folks might not be aware that a mental health parity bill was tacked on to the legislation.

The mental health parity bill was actually used as a bargaining chip in getting the bailout passed. The Senate included it to successfully attract 51 House members who had voted against earlier versions of the bailout, but who also wanted to see the mental health parity legislation go into effect before the end of the year.

Supporters of the mental health bill hail its passage as a victory in the fight to:

1) End stigmatization of addiction and mental illness, and

2) Make health care more affordable for those suffering from mental disorders.

The adoption of this legislation also ends a 12-year effort on the parts of Senator Peter Domenici (R-NM), the late Senator Paul Wellstone (D-MN), and hundreds of mental health advocates nationwide.

Senator Domenici’s daughter was diagnosed with atypical schizophrenia at a young age, which proved costly and difficult to treat.

This led him to devote a significant amount of time to seeing the mental health bill through, to meeting with and hearing the stories of thousands of those with family members having mental health issues. This may be considered the crowning achievement of his 35-year career in the Senate.

The legislation requires that group health plans of 51 or more employees cover mental illnesses at the same level as physical ailments.

It does not require that the plans offer such coverage, but that the coverage must be equal if they do offer the coverage.

The major focus of the bill is meant to prevent the higher co-payments, deductibles, and stricter limits on treatment (such as fewer covered inpatient and outpatient days) for addiction and mental illnesses.

The law allows managed care companies to refuse to pay for care if they decide it is not medically necessary, but makes it more difficult to do so. The insurers must reveal their criteria for determining necessity and their reason for denying any mental health claim.

Who will be affected?

Federal officials estimate that the law will improve coverage for 113 million people, including 82 million in employer-sponsored plans that are not subject to state regulation. The plans will go into effect on Jan. 1, 2010.

One of the reasons that support for this legislation has grown in recent years is because a number of companies now specialize in managing mental health benefits, and will continue to do so under this law. This makes the costs to insurers and employers more affordable.

Parity has also proven to be “doable” in terms of cost at the state level and in the health insurance program for federal employees, including members of Congress.

Mental health problems left untreated have a higher cost than the cost of treatment and prevention:

There is evidence that workers perform better after they are treated for mental and substance abuse problems, and

Scientists have found biological causes and effective treatments for many mental illnesses,

So it is a wonder that it took so long for this bill to pass, and that anyone would criticize the legislation.

But, as is often the case, opponents of the bill are already calling for its moderation or prompt repeal.

In an editorial published by the Baltimore Sun, Professor Richard Vatz of Towson University and Professor Jeffrey Schaler of American University argue that this legislation opens up a “Pandora’s box” for the health care system because:

The definition of mental illness is still under debate.

The American Psychiatric Association estimates that 50% of U.S. citizens are, or will be, considered mentally ill during their lifetimes.

The professors contend that the definition used is too wide-ranging. It includes a number of “adjustment disorders” or those illnesses attributed to patients who have “problems in living.”

In comparison, only 1.5% of the population is diagnosed with more severe mental illnesses such as schizophrenia and bipolar disorder.

The editorial suggests that too many people are diagnosed as having a mental illness, when they may in fact just be going through a rough time.

Mr. Vatz and Mr. Schaler assert that the treatments for many adjustment disorders should not be covered by insurance companies. Granting such coverage will just encourage spending on superfluous and unnecessary care.

The authors also question whether substance abuse problems are actual medical disorders, or whether they are the result of “personal lifestyle choices.”

They state that because “people can clearly stop or control their addictions through an exercise of free will, [addictions] in no way constitute diseases to which insurance should apply.”

Mr. Vatz and Mr. Schaler are subscribing to an American cultural belief that mental weaknesses are just a matter of willpower. That if a person really wants to change, he or she can do so. The willpower argument is a powerful tool that can be used to ration care.

Numerous studies have revealed that there are environmental and genetic factors that contribute to mental disorders like mild depression and substance abuse, and the mildness of the mental health problem can be in their favor. We can ration care so that only the seriously ill are given access, and that is the way that the bill is already written.

Mr. Vatz and Mr. Schaler are making a central argument that not all adjustment disorders should be considered mental illnesses, and that some patients can go without medical treatment. We certainly do not need to encourage more people to take unnecessary prescription drugs when lifestyle changes may prove to be just as effective. The question has become – is the individual truly able to change their lifestyle, to make the changes necessary? Or, could professional counseling and minimal drug prescription lead to a behavior change that prevents more costly and harmful behaviors later on?

We do not want to prevent individuals from seeking counseling or other types of medical care for substance abuse or even minor “adjustment disorders,” if such care will help them to be more productive, healthy and happy. It would be useful if we could calculate the gain in productivity and the increase in physical health as a result of this legislation and compare it with the total cost of the bill.

The criticisms invoke the bigger question of how we should ration medical care as a society. Mr. Vatz and Mr. Schaler favor rationing mental health services as a result of their cultural view of the nature of mental health.

As we have discussed in the past, one of the arguments given for the overall cost of our health care system rising rapidly is because we do not ration care. Our use (or overuse) of newer, expensive treatments is especially problematic, given the fact that many of these technologies, medications, and procedures:

Do not represent a significant improvement over their predecessors, or

Do not provide substantial benefit to the patient receiving the treatment.

But if providing mental health services to individuals, regardless of the severity of their condition, improves their overall health, why should we ration this care?

Do we need to ration care because the rate at which our health care bill is growing is unsustainable? How do we decide what care to ration?